CQC report explained · a nursing home
What the CQC found at St Margarets Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2022
Inspected but not rated; inspectors were assured about infection control, with some recording gaps for cleaning high-touch areas.
This was an announced, targeted inspection on 20 January 2022 during a COVID-19 outbreak. Inspectors looked at infection prevention and control, and asked about staffing pressures.
Inspectors found that the home had worked to contain the outbreak. Staff absences were low, shifts were covered by existing staff and the registered manager, and no agency staff were used.
The inspectors were assured about visiting arrangements, personal protective equipment, testing, admissions, social distancing and managing outbreaks. They were only somewhat assured about cleaning records because these did not specifically record all high-touch areas throughout the day.
The home was inspected but not rated overall. The Safe question was also inspected but not rated, so this report does not provide a Good, Requires improvement or Inadequate rating.
Outbreak response
The home had kept staff absences linked to COVID-19 low and covered shifts without agency staff.
“Staffing absences due to Covid-19 infections had been low, and their shifts had been covered by existing staff and the registered manager.” from the report
Visitor controls
Visitors were received in a designated area where vaccination status and self-test results were checked. Protective equipment and hand sanitiser were available.
“There was a designated area for receiving all visitors to the service, checking their vaccination status and their Covid-19 self test result.” from the report
Infection control
Inspectors were assured that the home was using PPE safely, accessing testing and managing infection outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Visits and contact
The report says the home was facilitating visits in line with current guidance, and people described regular family contact.
“We were assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Cleaning records
needs fixingCleaning schedules did not clearly record cleaning of all high-touch areas throughout the day. Inspectors signposted the provider to resources to improve this approach.
“Cleaning schedules that were in place did not specifically record the cleaning of all high touch point areas, throughout the day.” from the report
- 01How did you change the cleaning schedules after inspectors found that high-touch areas were not specifically recorded?
- 02How often are high-touch areas cleaned and checked during the day now?
- 03How would you manage staffing if COVID-19 or another infection caused more staff absences?
- 04How are visitors' vaccination status and COVID-19 test results checked?
- 05What current arrangements are in place for family visits during an outbreak?
This was a targeted inspection of infection prevention and control and staffing pressures during a COVID-19 outbreak; the service was inspected but not rated overall and the other questions were not assessed. This explanation was written from the published report of 28 January 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2021
Inspected but not rated; inspectors found generally good infection control, with some PPE use and staff risk assessments needing attention.
This was an announced, targeted inspection on 18 March 2021. Inspectors looked only at infection prevention and control measures during the COVID-19 pandemic.
The home was clean and had extra cleaning arrangements, PPE supplies, testing, visiting procedures and plans for managing an outbreak. Staff were trained in using PPE, and people were supported to keep in touch with family by telephone and IT.
Inspectors were assured that the home was admitting people safely, managing infection risks, using PPE, supporting testing and preventing or managing outbreaks. They saw one staff member whose mask did not fully cover their nose, and the manager said this would be addressed.
The home was not given an overall quality rating or a rating for safe care. The inspection was a focused check of infection control, so it does not tell you how the home performs in other areas of care.
Clean surroundings
Inspectors found the home visually clean and without unpleasant smells. Extra cleaning of shared and frequently touched areas was in place.
“The home was visually clean and free from odours.” from the report
PPE and testing
The home had plentiful PPE and handwashing facilities. COVID-19 testing procedures had been introduced for staff and residents.
“Appropriate testing procedures for COVID-19 had been implemented for all staff and people who used the service following national guidance regarding the frequency and type of testing.” from the report
Inconsistent mask use
needs fixingMost staff wore PPE correctly, but inspectors saw one member of staff whose mask did not fully cover their nose in communal areas. The manager said this would be dealt with promptly.
“However, we observed one member of staff whose mask was not covering their nose fully while in communal areas of the home” from the report
Staff risk assessments planned
minorThe manager had discussed staff who might be at increased risk from COVID-19, but individual formal risk assessments were still planned.
“The registered manager planned to complete individual risk assessments for each member of staff” from the report
- 01How was the PPE mask issue identified during the inspection dealt with afterwards?
- 02Were individual COVID-19 risk assessments completed for all staff who might be at increased risk?
- 03What infection control arrangements are currently used for visitors and compassionate visits?
- 04How often are communal and high-touch areas cleaned and checked?
- 05What is the current process for testing residents and staff and managing a COVID-19 outbreak?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; the service was inspected but not rated and other areas of care were not assessed. This explanation was written from the published report of 8 April 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of St Margarets Nursing Home
6 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2021Inspected but not ratedSafe: Inspected but not rated
- December 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 17 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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